Asian patients may receive inferior care

Editor—Patel et al report an ecological study which shows that at the practice level the proportion of patients who are South Asian is a significant determinant of the level of prescriptions for lipid lowering drugs.¹ Presumably this means that South Asian patients, even though they are more likely either to have heart disease or to be at higher risk of heart disease, are less likely to receive appropriate treatment with lipid lowering drugs.

We reported results from a detailed study of 358 patients with angina from 15 general practices that we carried out in the metropolitan borough of Sandwell in the West Midlands, England, providing direct evidence that non-white patients receive a less good quality of care.² We found that non-white patients were significantly less likely to receive short acting nitrates (P<0.001). They were also less likely to be given advice on smoking cessation, weight, exercise, and alcohol consumption, and were less likely to have their blood pressure checked (all P<0.0001). Women were less likely to receive β blockers (P<0.01), and patients aged 65 or over were less likely to receive a cholesterol check (P<0.0001).

Furthermore, stratified analysis by practice showed significant associations between practice and ethnicity as explanatory factors and, as outcome variables, β blocker prescribing, smoking cessation advice, blood pressure checks, and cholesterol checks. Since the practice variable accounted for some of the variation in these outcome measures, we concluded that there may have been a systematic tendency for some practices not to carry out these interventions for certain groups. It is well known that many inner city areas have both a high proportion of ethnic minority patients, as well as a high proportion of single handed and less well resourced general practices. These practices find it hard to recruit clinical staff, are more often overburdened, and probably have less time and resource to carry out audits of the equity of their services than practices in more affluent areas. There is also evidence that socioeconomically deprived patients and South Asian patients wait longer for treatment than affluent white patients.³,⁴ The result of this structural inequity is of course a perpetuation of Hart's well known inverse care law⁵—those with the greatest need (and with the greatest propensity to benefit) are likely to get the least.